MEDICAL ECONOMICS
TMA vs. Cigna Cigna referral policy draws TMA challenge
BY AMY LYNN SORREL Texas Department of Insurance (TDI) reg- ulations on preferred provider networks were barely a month old in August when the Texas Medical Association renewed its challenge of a Cigna practice the association says violates state law and could prevent physicians from giving their patients the care they need.
TMA filed the complaint after Cigna notified physicians it will continue enforcing an old policy on out-of-network referrals. Barring an emergency, every time Cigna patients plan to leave the network for just about any type of care, their physician must fill out a form explaining and acknowl- edging the referral, whether or not the patient follows through on it. Physicians also must disclose in writing any kind of financial inter- est in the physician practice or fa- cility to which they are referring a patient, or check a box even if they don’t have an interest. The referral could include another physician, lab, facility, surgery center, or other out-of-network entity. Doctors must keep the doc- ument indefinitely, and they are subject to audits by Cigna. Physicians who violate the
said TMA Vice President of Medical Economics Lee Spangler. “There are other tools Cigna can use to address abuses [of out- of-network referrals]. Cigna has chosen instead to impose a policy that burdens all physicians.” TMA is asking TDI to review the legality of the Cigna policy and its impact on patients and to consider “all possible sanc- tions” against the insurer. They range from barring use of the form to fines.
State law does not put TDI
“It’s important for Cigna’s in-
network doctors to be part of
the conversation through the use of the out-of-network form.”
policy risk losing their preferred provider network status, their contract, or payment. TMA’s Payment Advocacy Department is tracking related complaints from physicians. In at least one instance, TMA was told a physician had to appeal Cigna’s pay- ment denial when he referred to an out-of-network patholo- gist, even though the health plan at the time had none in the network area. The appeal has not been resolved yet. Cigna says the policy curtails inappropriate out-of-network
referral practices and protects patients and employers from excessive costs.
But the form appears to “put an obstacle between patients and their basic insurance coverage and right to access care,”
under any kind of timeline to respond to complaints. A spokes- person says the agency contacted Cigna within weeks of receiving TMA’s complaint and was review- ing the health plan’s response in light of the new regulations.
At it again
TMA filed a similar complaint with TDI about the policy when Cigna first imposed it in 2010. TDI didn’t take any action back then, possibly because the new rules were still being developed. At press time, TDI was still re- viewing the latest complaint. In the first complaint, TMA of- ficials alleged the Out-of-Network Disclosure Form violates state laws guaranteeing not only pa- tients’ right to freely choose any
physician or other provider without restriction by an insurer, but also physicians’ right to discuss and recommend all treat- ment options to their patients. TMA reiterated the same stance three years later. In addition, TMA officials say, Cigna’s policy is more trou- bling now because it appears the company has not sufficiently adapted the policy to fall within the limited scope of the new TDI regulations that address network adequacy and general market conduct. (See “Adequate to Inadequate,” March 2013 Texas Medicine, pages 21–25) Despite TMA’s objections, TDI approved regulations allow-
November 2013 TEXAS MEDICINE 43
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60